"The NHS will last as long as there are folk left with the faith to fight for it"Aneurin Bevan

Monday, 16 August 2010

Mixed Sex Accommodation

No one thinks that mixed sex accommodation is the preferred situation, but there are more important things. Indeed, Lord Darzi (someone who knows a lot about healthcare) has said that single-sex wards across the NHS was an "aspiration that cannot be met". It is right to try and achieve this aspiration, but not when it could affect care.

There was no real policy decision that wards had to be mixed sex, the situation just became the norm as wards became more specialised. The problem is that modern healthcare is high tech and expensive. Sometimes there are expensive pieces of equipment and patient beds are configured to use it, but more significant are the skills of the staff - it is better to group together the patients with a similar condition and have the staff with the specific skill within the ward than to have the skilled staff moving between wards.

The problem with an obsession with single sex accommodation is that it puts a non-medical need above medical needs.

There have been a lot of complaints over the last decade about mixed sex accommodation, and for good reason. Culturally we are conditioned to be acutely aware of the sexual differences between men and women. When we are in hospital we are at our most vulnerable so our deepest conditioning and concerns become amplified. Without a cultural change we will always have this problem: people prefer to be treated with people of the same sex.

The last Labour government recognised this and brought about a programme to change mixed sex to single sex wards, but rightly they recognised that this was secondary to improvements in medical care. They also recognised that such a policy is very expensive and so grants were made available. From April this year all hospitals in England are supposed to be compliant with single sex accommodation and in February this year the department of health announced that "97 percent of NHS trusts meet single-sex accommodation standards".

I have written about this before but it is worth mentioning it again. Bed occupancy rates are high, because empty beds are expensive resources not being used. There's a general rule of thumb that a rate of 93% is a good compromise between the cost effectiveness of using all resources to their full extent and having capacity so that a free bed is available when needed.

However in the last few years there have been a lot of pressure on hospital beds. Last September the NHS framework for continuing care came into force without additional resources for local authority social services. Patients cannot be discharged if continuing care arrangements are not in place for them. The result was that bed occupancy at hospitals rose last September. This is a problem that can only get worse as deep cuts are made in local authority social services departments. Further, in the last year there has been an unexpected rise in emergency admissions which has no correlation with explainable factors like weather conditions. The bed occupancy rate across the NHS is very high and it will get worse.

In an ideal world a hospital will have two of everything. But this is not an ideal world. You cannot simply take two wards and say that from this point on one will be male and one will be female. Instead, wards have to be reconfigured with single sex bays so that the same specialised staff can treat both male and female patients without the patients seeing each other. However, single sex accommodation is not simply the sleeping arrangements: there must be no contact at all between patients of different sexes. This means that patients must be able to use a bathroom without walking past a patient of the opposite sex. To do this bathrooms have to be moved and perhaps additional bathrooms have to be built. This will be costly and will reduce the numbers of beds.

Another problem to bear in mind is that when you are upgrading a ward to single sex what do you do with the patients? The high bed occupancy rate means that there are not enough free beds to move patients during the changes. It takes a lot of organisation to arrange for the additional beds, and often this means moving more than just one ward since the most vulnerable patients must be protected. In the past I have spoken to some hospital managers about this issue and they have pointed out to me how complicated the process can be: they told me that you need a lot of time, and resources to make alternative arrangements.

Let's be clear about this, the previous Labour government said that all hospitals had to be compliant from April 2010, single sex compliance is not a new policy. What does compliance mean? If a patient is put in a ward/bay with patients of the opposite sex and there is no clinical justification then there is a breech of compliance. However, there is not just one breech. If there is a bay of six beds with five women and a man is put in the free bed then that represents six breeches of compliance and each breech carries with it a financial penalty. (There are no limits to the amount of fines that can be applied.) That Draconian policy came from the previous Labour government, and hence it shows how serious they were about the issue.

So if there was already a push towards single sex accommodation (and 97% compliance) what is the problem with Commissar Lansley's latest diktat that all hospitals have to be compliant by the end of this year?

Well the first thing is that it is uncompromising: compliance will have to "apply to all wards except for intensive care and A&E". This discriminates against the smaller hospitals who do not have the resources to duplicate expensive equipment and expertise. Under the current rules if there was a clinical justification then sexes could be mixed. Lansley is not compromising. When I spoke to a hospital manager about single sex accommodation a few weeks ago she said that often when it came to single sex compliance the hospital were "offsetting privacy against safety" I know which I would prioritise. Lansley is prioritising single sex accommodation compliance over clinical needs.

There is also the issue of the timescale. Currently 97% of trusts are compliant, which appears that the majority of work has been done. However, the last 3% are an issue because they are the more difficult cases. They are the older hospitals where the age of the buildings give rise to more problems, and they are the smaller hospitals which do not have the resources or staff to make the re-configurations. It takes time and money to complete the remainder. The problem is that Lansley has said all hospitals must be compliant by the end of this year, just four months. As I have said above, a lot of planning must be done to provide extra accommodation, and Lansley has rather dimly put his deadline in the middle of the period when hospital occupancies are the highest. Presumably the simplest way to make extra capacity available is not to have the patients in the first place. So in the next weeks expect hospitals to postpone elective operations until next year. This will significantly increase waiting lists. Think about this: if you need an operation, and the choice is either sooner in a mixed sex ward, or later in a single sex ward, which would you choose?

Then there is the money. The last government provided grants for hospitals to convert mixed sex wards to single sex wards. This government will not. Lansley has already announced that Foundation Trusts (about half of all hospital trusts) will not have access to public money. This means that to finance single sex accommodation Foundation Trusts will have to take out commercial loans.This is pushing hospitals towards privatisation or spiralling debt.

Lansley is deliberately creating a situation where NHS hospitals will fail. The decision about single sex accommodation will deliberately increase waiting lists and put hospitals into debt. This is yet another part of Lansley's sink or swim policy which is intended to close NHS hospitals.

UPDATE:

A spokesman for the Royal College of Nursing says: "They want to be able to protect their privacy and maintain their modesty. However, in a survey covering 82 different aspects of patient care, single sex wards came 62nd overall."